Chronic Care Patient-Centered Medical Home in Baltimore City is searching for a dynamic Transitional Care Manager with experience with the Baltimore City population to help coordinate care and manage a population of patients in a team-based model—a Chronic Care Patient-Centered Medical Home.
The Transitional Care Manager must be a Registered Nurse, with experience managing a complex patient base and be familiar with Baltimore City, MD both with its population as well as its geography.
The Transitional Care Manager will be a key member in the multi-disciplinary team, working in collaboration with a multitude of other medical personnel, to help patients, become healthier and lower unnecessary Emergency Department and Hospital utilization.
The Transitional Care Manager will be responsible for navigating patients through the care continuum. The Transitional Care Manager works with patients, caregivers, and providers (both within our facility in Baltimore, as well as coordinating care with community partners to help reduce preventable ED visits and hospitalizations. The Transitional Care Manager will be responsible for developing a plan of care for the member tailored to eliminate barriers to care and meet treatment plan goals.